Health Insurance and Public Policy: Risk, Allocation, and Equity

By Miriam K. Mills; Robert H. Blank | Go to book overview

2
Biting the Bullet? Post-1980
Congressional Processes and
Medicare Decisions

Katherine A Hinckley and Bette S. Hill

It has been conventional wisdom in political science that Congress is more likely to allocate benefits to narrow interests than diffuse ones. Generally speaking, its decisions will tend to offer concentrated benefits to narrow interests, while spreading the costs broadly among taxpayers ( Lowi, 1963; Wilson, 1973; Mayhew, 1974). This occurs primarily because narrow interests tend to be more attentive and better organized than the general public, and hence more willing and able to reward or punish legislators for their actions.

This conventional wisdom has important implications for health policy, as it suggests that provider interests will be able to block action that imposes severe costs on them, even though the more general public might thereby benefit ( Marmor, Wittman, and Heagy, 1983). The success of groups like the American Medical Association (AMA) in preventing enactment of national health insurance, and in forcing significant concessions on Medicare policy, would appear to substantiate the basic argument. For that matter, Medicare itself, which provides health insurance for only the elderly portion of the population, yet is paid for by the whole, might be seen as evidence of the power of special interests.

In recent years, however, studies have emerged showing that Congress does not always favor the "special interests" ( Derthick and Quirk, 1985; Birnbaum and Murray, 1987; Arnold, 1990). Under some conditions, legislators will grant benefits to more diffuse, general interests, even simultaneously imposing sizable costs on narrower groups. This work squares much better with the fact that over the period from 1980 through 1986, Congress

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